Failure to Maintain Clean Resident Room and Safe Environment
Penalty
Summary
Surveyors identified that the facility did not maintain a safe, clean, comfortable, and homelike environment for a male resident with dementia, bipolar disorder, schizophrenia, stroke history, type 2 diabetes, major depressive disorder, Alzheimer's disease, and dysphagia. His MDS showed he required setup or clean-up assistance with personal hygiene and his care plan noted risk for increased confusion and decline in ADLs as his disease progressed. On observation, the resident was non-interviewable and seated in his wheelchair in his room with a urinal on the table in front of him that was about one third full of dark yellow urine. There were approximately 25 small bugs visible on and around the urinal and an upside-down foam cup, and the urinal appeared stained and the plastic corroded. A CNA reported that the last time he had been in the resident’s room was around 9:00 AM that day and that the resident liked to empty his own urinal and sometimes refused to have it emptied, but that morning he did not refuse. The CNA stated the toilet in the resident’s room was not working, so he had to empty the urinal elsewhere. During this same observation, the resident’s curtains were noted to be stained with a brown substance, and the CNA described the curtains as “nasty” and acknowledged there were a lot of bugs around the urinal. The Maintenance Director, who stated it was his responsibility to monitor for pests and to be notified of pest issues, had not entered the resident’s room that day. After viewing a photo of the urinal, he identified the bugs as gnats and estimated, based on their number, that the urine had likely been sitting for two days. He also stated that staff were supposed to notify him or housekeeping when curtains needed to be removed for cleaning and agreed the curtains looked dirty and should have been changed. In addition to the conditions in the resident’s room, surveyors observed environmental deficiencies in the facility’s east hallway, where laminate floor paneling was peeled off and raised. Another resident reported that a resident had peeled off the floor. The Maintenance Director stated the damaged flooring would be repaired the following week and that, to his knowledge, no residents had tripped over it. The DON stated that pest control services occurred every two weeks and that it was everyone’s responsibility to monitor resident rooms for pests, but he had not been in this resident’s room that morning and stated he did not know how residents could be affected by pests. The Administrator reported that the facility had policies for maintenance, housekeeping, and resident rights for a homelike environment, that everyone was responsible for monitoring and reporting environmental concerns, and that he assumed urinals were emptied once a day. Facility policies reviewed stated that the residence would be kept clean and well-maintained through regular cleaning and preventive maintenance, and that residents had the right to safe, decent, and clean conditions.
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